Anaesthesia and Intensive Care最新文献

Failing high-stakes examinations in specialist medical training has devastating effects on trainees, both personally and professionally, with some trainees requiring multiple attempts. Factors enabling the transition from failure to success are under-explored. This study aims to understand how intensive care trainees, taking multiple attempts at the final high-stakes exam for progression to specialist, made the transition from failure to success, and their lived experience of the journey. This qualitative study applied grounded theory design, conducting 11 in-depth interviews. All participants had had two or more failed attempts before achieving success in the final high-stakes examination, a critical hurdle in achieving Fellowship with the College of Intensive Care Medicine. Additional data included exam reports, an external review of the exam processes, and research notes. To achieve exam success participants needed to reconstruct their sense of self, develop a growth mindset and identify as a competent intensivist. The constructed theory, 'Identifying as an intensivist', relates to professional identity formation and 'thinking, acting and feeling' as an intensivist. 'Identifying as an intensivist' was integral to overcoming exam failure for intensive care trainees. Professional identity formation as an aspect of remediation for high-stakes assessments in medical specialty training has not been well described. Furthermore, assessment processes should be constructed to align with a professional identity reflecting the values and diversity of the specialty.

Little is known about the characteristics of potentially inappropriate or unnecessarily prolonged intensive care unit (ICU) admissions in Australia, nor the exposure rate of non-ICU clinicians to dying ICU patients. We conducted a single-centre retrospective cohort study at a university-affiliated hospital in Victoria, Australia, of patients admitted to the ICU between January 2022 and June 2023, who transitioned to end-of-life care during their ICU admission. Decisions regarding appropriateness were adjudicated during a bi-weekly morbidity and mortality meeting. Out of 287 patients 279 were included in the final analysis. One hundred and eight (39%) patients were deemed to have had a potentially inappropriate admission, and 37 (13%) were deemed to have had a potentially inappropriately prolonged admission. Significantly higher proportions of patients were admitted from either the ward (32.4% versus 22.4%, P=0.02) or another hospital (15.7% versus 6.4%, P=0.02) if they were deemed to have had a potentially inappropriate admission. Significantly higher proportions of patients deemed to have had a potentially inappropriately prolonged admission had treatment limitations (16.2% versus 40.5%, P=0.006), lower Australian and New Zealand Risk of Death scores (median score 27.2 versus 45.5, P=0.006) and a clinical frailty score of 5 or more (63.9% versus 45.1%, P=0.048). They also had a significantly longer median ICU length of stay (median length of stay 13.4 days versus 2.6 days, P <0.001) and received significantly higher rates of invasive supports such as tracheostomy (16.2% versus 1.2%, P <0.001). The four major themes linked to these admissions were 1) lack of planning/appropriate treatment limitations, 2) lack of recognition of dying, 3) issues with communication/consensus and 4) provision of highly invasive treatments. The median rate of exposure of individual ward-based clinicians was 1 dying ICU patient per 18 months. Early framing of goals of care, reassessment of treatment goals during an ICU admission, dedicated communication skills training, and embedded frailty assessments might reduce non-beneficial and prolonged ICU admissions.

Evaluation of the clinical learning environment in teaching hospitals is an important quality improvement metric. The measure for the anaesthesia theatre educational environment is a validated tool measuring the educational environment in the operating theatre, specific to anaesthesia. Monitoring the learning environment provides information about the impact of interventions, the influence of major events such as a global pandemic and is increasingly linked to accreditation requirements. This study was conducted to establish a baseline for monitoring the impact of interventions designed to improve the learning environment. We surveyed trainees at the Royal Melbourne Hospital, a trauma hospital in Melbourne, Australia, aiming to identify areas for improvement in the clinical learning environment and provide a needs analysis for interventions to help anaesthesia trainees set and achieve learning goals. This single centre survey study occurred over a 6-week period from May 2023. Medical staff who had undertaken a training rotation at Royal Melbourne Hospital in the past 6 months were eligible. Twenty-six responses were received (response rate 39%). Areas for improvement included setting learning goals (mean 3.9, median 5, interquartile range 4-5) and assessment of trainee performance (mean 3.8, median 4, interquartile range 3-5). Over 80% of participants had received no training in how to set a learning goal, despite over 90% indicating that it would be of value to their experience. Trainee perception of the learning environment was positive but there is opportunity for improvement. We are planning interventions to assist trainees and consultants to set learning goals while working in a dynamic clinical learning environment.

Simulation-based training can be valuable for teaching bronchoscopy to intensivists, providing a risk-free training environment. We developed, implemented and evaluated a simulation-based flexible bronchoscopy training program for intensive care Fellows and intensivists. This paper presents the development of its design and lessons learned. We used the Analyse, Design, Develop, Implement and Evaluate model for developing and evaluating the training program (Analysis and Design - phase 1, Development - phase 2, Implementation - phase 3, Evaluation - phase 4). In phase 1, two intensivists formulated learning objectives for bronchoscopy in an intensive care setting, which guided the identification and development of training materials and the preliminary training program (phase 2). In phase 3, we tested this program and gathered feedback from participants to guide program modifications. After implementing the adjusted training, we measured participants' satisfaction using a survey based on closed- and open-ended questions (phase 4). Fifty-seven participants attended the training, with 18 (32%) responding to the questionnaire. Respondents highly appreciated the training program, with median satisfaction scores of 4 or higher on a five-point scale for all closed-ended questions. Respondents appreciated the supervision and feedback and found the simulator equipment relevant for learning bronchoscopy. This description of the program's development and its evaluation results can serve as a valuable resource for those wishing to establish similar training programs. We recognise that further implementation of evidence-based instructional design principles might enhance the training program's scientific foundation and effectiveness. We therefore recommend a more evidence-based approach for the design of future bronchoscopy simulation training programs.

There is limited data regarding the mortality risk factors for Australian nonagenarians requiring intensive care unit admission. The objectives of the study were to determine the mortality rates, length of stay, and indicators of poor outcomes in nonagenarian patients admitted to the intensive care unit. Data were retrospectively collected from a single-centre university hospital in Australia over a 10-year period. Cox regression survival analysis, hazard ratios (HRs) and receiver operating characteristic curves were used to assess characteristics and associated survival. A total of 25,766 adult patients were admitted to the intensive care unit during the study period, of whom 89 (0.35%) were nonagenarians. The intensive care unit and hospital mortality rates of nonagenarians were 10.1% and 22.5%, respectively. The Australian and New Zealand risk of death model was the most significant predictor of mortality among the risk scoring systems. Nonagenarians who experienced a cardiac arrest had the highest hazard of death in the intensive care unit (HR 7.60, 95% confidence interval (CI) 1.49 to 38.66, P = 0.015) and throughout their hospital admission (HR 6.77, 95% CI 1.52 to 30.28, P = 0.012). Acute renal failure and invasive ventilation had a significantly increased hazard of death in the intensive care unit and hospital admission. Lactate levels also demonstrated a significant increase in the hazard of death per 1 mmol/l increase (HR 1.64, 95% CI 1.3 to 2.08, P < 0.001). Over the study follow-up period of a minimum of 3.5 years, 50 of 89 patients (56.2%) died. Intensive care unit and hospital mortality among nonagenarians admitted to the intensive care unit was relatively low. These findings support early identification of mortality risk factors, allowing for the timely implementation or withdrawal of interventions.

Smoking increases anaesthetic and surgical complications. The perioperative period provides an opportunity to give advice and initiate ongoing support to patients who smoke. Our aims were to determine perioperative smoking patterns and how well patients were supported to reduce smoking as well as compliance with the Australian and New Zealand College of Anaesthetists guidelines on smoking. We surveyed all adults having non-emergency surgery at Wollongong Hospital over an 8-week period in 2021. For those who smoked, we analysed their medical record for identification of smoking status and smoking cessation pharmacotherapy prescription. Sixteen per cent of patients (n = 111) had smoked in the 30 days before surgery. Of that group, 83% did not think that smoking might cause a problem with their surgery or anaesthetic, and 46% did not report receiving advice to stop smoking. When advice to stop smoking was given, it was associated with an attempt to quit, especially when given by a surgeon. Attendance at the preadmission clinic was associated with the provision of smoking cessation advice but not a quit attempt. Nicotine replacement therapy was used by 11% prior to surgery, and only 7% immediately post-surgery. Our findings show low rates of perioperative smoking cessation advice and nicotine replacement therapy prescription, similar to those reported by other studies over the past two decades in Australia. It provides further evidence that the Australian and New Zealand College of Anaesthetists and other society guidelines alone have not led to major improvements in our management of perioperative smoking, and that hospital-specific routine interventions are needed.